Polycystic ovarian syndrome (PCOS) affects thousands of women in
the US and is a common cause of infertility. Androgen excess and insulin
resistance are hallmarks of the disorder. Understanding the pathogenesis
of PCOS helps understand the breakthroughs in treatments available to
practitioners. This review will examine naturopathic treatment options
for women with PCOS.

Introduction

Polycystic ovarian syndrome (PCOS) is the most common
endocrinopathy of reproductive-age women in the US, affecting roughly
10% of this population. It accounts for 75% of women with amenorrhea and
85% of women with androgen excess/hirsutism. (1) in 1935, Stein and
Leventhal published their report of seven women with unexplained
anovulation, amenorrhea, hirsutism, obesity, and enlarged
polycystic-appearing ovaries. Ovarian wedge resection resulted in two
pregnancies and regular cycles in remaining five. Ovarian wedge
resection involves removing a section of the tissue that then allows
ovulation to occur, although the exact mechanism is unclear. (2) Since
then, much has been learned about this disorder in terms of clinical
manifestations, etiology, diagnosis, and treatment.

Clinical Manifestations

The most common signs and symptoms that women with PCOS present
with include menstrual irregularity, hirsutism, acne, acanthosis
nigricans, infertility, obesity, and increased risk of cardiovascular
disease. Menstrual irregularity presents as either amenorrhea or
oligomenorrhea due to anovulatory cycles. A small percent of women with
PCOS, even though they are anovulatory, continue to menstruate
regularly. It is estimated that 40% of hirsute women who have normal
menses are anovulatory. (3) Hirsutism and acne in women with PCOS are
signs of androgen excess and are present in 70% of women with PCOS and
10% of women without PCOS. (4) PCOS is a common cause of female
infertility due to anovulatory cycles, and infertility is frequently the
initial reason the patient seeks medical advice. Infertility affects 75%
of obese women with PCOS. (5) The obesity seen with PCOS is typically
characterized by an increase in the waist circumference (<35 inches)
as opposed to overall obesity. This type of obesity is associated with
insulin resistance, glucose intolerance, and dyslipidemia. (6), (7)
Dyslipidemia is common in women with PCOS; up to 70% of PCOS patients in
the US have dyslipidemia. Women with PCOS have higher LDL and non-HDL
cholesterol regardless of body size, placing them at risk for
cardiovascular disease. (8), (9)

[ILLUSTRATION OMITTED]

Etiology and Diagnosis

PCOS remains a syndrome, as no single criterion is diagnostic. It
is mainly a disorder of excessive androgen production, use, or
metabolism with oligo- or anovulation. In 2003 a consensus workshop
sponsored by the European Society of Human Reproduction and Embryology
(ESHRE) and the American Society of Reproductive Medicine (ASRM) in
Rotterdam, Netherlands, agreed upon a new definition for diagnosing
PCOS. In order to diagnose PCOS, two out of three criteria must be
present (10):

It is important to exclude other etiologies with
polycystic-appearing ovaries, such as hypothyroidism, hypothalamic
amenorrhea, Cushing's syndrome, congenital adrenal hyperplasia, and
ovarian/adrenal tumors. (11) In PCOS, the mechanism behind the excessive
androgen production and ovulatory dysfunction has been difficult to
pinpoint, and the etiology of PCOS is most likely multifactorial.
Understanding the etiology is key to understanding the treatment. There
are three main concepts in the development of PCOS.

First is the role of luteinizing hormone (LH). LH is normally
secreted in a pulsatile manner. However, women with PCOS have an
increase in both the LH frequency and amplitude, resulting in increased
24-hour secretion. Increased LH leads to an increase In androgen
production by the theca cells within the ovary. (12), (13)

Second is the alteration in insulin secretion and action, which
results in hyperinsulinemia and insulin resistance. Insulin resistance
is a characteristic metabolic disturbance associated with PCOS. Both
obese and nonobese women with PCOS have a higher incidence of insulin
resistance and hyperinsulinemia than age-matched controls. (12) There is
a strong correlation between insulin resistance and hyperandrogenism.
(8) Insulin acts synergistically with LH to enhance androgen production
in the ovarian theca cells. Insulin also decreases hepatic synthesis and
secretion of sex hormone-binding globulin (SHBG), thus increasing the
amount of free testosterone. (12), (13)

A third component of PCOS is a defect in androgen synthesis that
results in increased ovarian androgen production. This is due in part to
an increase in ovarian enzymatic activity involved in the synthesis of
testosterone precursors, leading to the increased testosterone seen in
PCOS. (12), (13)

When discussing the etiology of PCOS, environmental triggers should
not be overlooked, as recent research has shown that hormone-disrupting
chemicals are linked to PCOS. Phthalates, bisphenol-A, cadmium, and
mercury have all been correlated with PCOS. The mechanism includes
altering hormones to cause anovulation, development of insulin
resistance, and hyperandrogenemia. This evidence is outlined in the book
8 Weeks to Women's Wellness. The Detoxification Plan for Breast
Cancer, Endometriosis, Infertility and Other Women's Health
Conditions (Smart Publications; April 2011).

Naturopathic Treatment Approach

A therapeutic approach to managing PCOS includes addressing the
underlying disorder, managing the presenting symptoms, and reducing the
risk of cardiovascular disease.

Methods to achieve these goals include lowering estrogens and
androgens by stimulating SHBG and inhibiting 5-alpha reductase to
inhibit conversion of testosterone to DHT, and modifying insulin
resistance and lowering oversecretion of insulin.

Weight reduction and exercise have been shown to help obese women
with PCOS. A study done with 18 infertile obese women with PCOS and
menstrual irregularities involved a 6-month weight-loss diet and
exercise plan. The obese women with PCOS were compared with age-matched
controls. The women showed an 11 % reduction in central fat, a 71%
improvement in insulin sensitivity index, a 33% fall in fasting insulin
levels, and a 39% reduction in LH levels; and nine of the women began to
ovulate. (14) By using a lifestyle program that promotes realistic
weight-loss and exercise goals, not rapid weight loss, participants were
able to sustain an improvement over a 6-month period in insulin
sensitivity and ovulation.

Botanicals traditionally used to treat PCOS include:

1. Serenoa repens (saw palmetto)

2. Urtica dioica (nettle)

3. Camellia sinensis (green tea)

4. Gymnema sylvestre

5. Trigonella foenum-graecum (fenugreek)

6. Glycyrrhiza glabra (licorice root)

7. Mentha spicata (spearmint)

Recent research has focused on the mechanism of each plant in
addressing the pathophysiology of PCOS. Saw palmetto inhibits 5-alpha
reductase, therefore inhibiting conversion of testosterone to DHT. It
reduces androgen effects at the hair follicle and pilosebaceous unit,
decreasing hirsutism and acne. (15) The study dose was 200 mg twice a
day. Nettle root, not leaf, 300 mg twice a day, binds to and increases
SHBG, thus decreasing the amount of free testosterone. (16), (17) Green
tea also increases SHBG, thus decreasing testosterone, and it promotes
weight loss. (18) A recent study took 34 obese Chinese women with PCOS
and randomized them into either treatment with green tea capsules or
placebo for 3 months. The body weight of the green-tea group decreased
by 2.4% after treatment, whereas the body weight, body mass index (BMI),
and body fat content of the control group were significantly higher
after 3 months. The dose used was 270 mg of ECGC from green tea. (19)
Gymnema and fenugreek are typically used in patients with diabetes and
hyperlipidemia, which is often present in women with PCOS. Gymnema
reduces blood glucose, total cholesterol, triglycerides, and LDL and can
increase HDL. (20) Fenugreek lowers fasting glucose levels and
postprandial glucose, and improves glucose tolerance. (21)

Licorice can also decrease testosterone synthesis in women. (22)
Nine healthy women, aged 22 to 26 years, received 3.5 g of licorice
containing 7.6% glycyrrhizic acid (0.25 grams total glycyrrhizic acid
per day) q.d. for 2 months. Mean total serum testosterone significantly
decreased after one and two months of treatment with no change in blood
pressure, often a reported side effect of licorice. (23) Lastly,
spearmint tea is a beneficial treatment for women with PCOS. Forty-two
women with PCOS and hirsutism drank spearmint tea b.i.d. for 30 days,
compared with a placebo tea. The women in the spearmint group had lower
testosterone levels, higher FSH and LH, and subjective improvement in
hirsutism. (24)

Other nutrients to consider are D-chiro-inositol and maitake
mushroom. D-chiro-inositol (DCI) was given to 44 obese women with PCOS
to determine its effects on ovulation, hormones, and insulin. Twenty-two
women were given 1200 mg once a day for 6 to 8 weeks and compared with
22 controls. The women taking DCI had decreased insulin and
testosterone, and 18 out of 22 ovulated. (25) Maitake mushroom extract
was given to women with PCOS and compared with women with PCOS taking
clomiphene to induce ovulation. After 3 menstrual cycles, the maitake
group had an ovulation rate of 76.9% and the clomiphene group had an
ovulation rate of 93.5%. (26) The proposed mechanism is that maitake
mushroom enhanced insulin sensitivity.

Finally, it is important to evaluate and treat any underlying
environmental toxins that may be contributing to PCOS, Educate on
avoiding chemicals found in food, air, water, cosmetics, plastics, and
household products. Remove any stored chemicals from the body through
proper detoxification methods.

Summary

Polycystic ovarian syndrome is a complex condition presenting with
menstrual irregularities; oligo- or anovulation, often affecting
fertility; signs of hyperandrogenism such as acne and hirsutism; and
insulin resistance, increasing the risk of cardiovascular disease. Many
natural treatment options are available and aimed at addressing the
underlying pathophysiology behind PCOS. PCOS can be successfully managed
with lifestyle modifications, botanical medicine, and other nutrients.
Proper management can reverse all symptoms, restore fertility, and
decrease risk of future cardiovascular disease.

Dr. Marchese is the author of 8 Weeks to Women's Wellness: The
Detoxification Plan for Breast Cancer, Endometriosis, Infertility, and
other Women's Health Conditions. Dr. Marchese graduated from the
National College of Naturopathic Medicine. She maintains a private
practice in Phoenix, Arizona, and teaches gynecology at Southwest
College of Naturopathic Medicine. She was named in Phoenix
Magazine's 2010 Top Doctor Issue as one of the top naturopathic
physicians in Phoenix. Dr. Marchese is a contributing author for the
Townsend Letter and lectures on topics related to women's health
and environmental medicine throughout the US and Canada. She is past
vice president of the Arizona Naturopathic Medical Association and
current member of the board of directors for the Council on Naturopathic
Medical Education.